Inspection on 31/07/09 for The Laurels

This inspection was carried out on 31st July 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Laurels 01/12/08

The Laurels 27/12/07

The Laurels 15/11/06

The Laurels 06/02/06

The Laurels 16/08/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Laurels West Carr Road Attleborough Norfolk NR17 1AA Lead Inspector Mrs Judith Last Key Unannounced Inspection 31st July 2009 10:00 DS0000064440.V376976.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Laurels Address West Carr Road Attleborough Norfolk NR17 1AA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01953 455427 Gooderham@btconnect.com Goodwood Care Homes Ltd Manager post vacant Care Home 51 Category(ies) of Dementia (39), Old age, not falling within any registration, with number other category (51), Physical disability (51) of places The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE (maximum number of places - 39) Old age, not falling within any other category - Code OP Physical Disability - Code PD The maximum number of service users who can be accommodated is: 51 18th May 2009 2. Date of last inspection Brief Description of the Service: The Laurels is a single storey building that is registered as a residential home. The registration has changed to include residents with dementia. The registration for older persons without dementia or for adults over 50 with physical disability is only for those residents who are already in the home. The long-term plan is that only service users suffering from dementia will be accommodated and so the home cannot now admit people who are not older people who also have dementia. The home provides 45 single bedrooms and 3 shared rooms. Twelve of the rooms have en-suite facilities. There are other toilets located throughout the building as well as bathrooms providing a range of different equipment to assist service users safely and in comfort. The shared rooms are only used to provide care to residents that chose to share together. The home does not provide nursing care but health care is by access to community resources. A chiropodist and dentist visit the home as required and a hairdresser visits weekly, for which additional charges may be made. Weekly charges are from £347 to £625 per week with the higher range predominantly applying to the en-suite rooms. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. People at this home are having an Adequate (One star) service at the moment. Before we went to the home we looked at all the information we had about it. This included the history of the home, information that had come to us from other sources and from our previous reports. We also had information from relatives, people and working in the home, and that the manager sent us in her Annual Quality Assurance Assessment. We visited unannounced. The Commission’s specialist pharmacist inspector, Mr Mark Andrews, carried out an audit of the medication. Mrs Judith Last carried out the remainder of the inspection. During our visit the main method of inspection we used is called “case tracking”. This means that we look at records to see what they say and they try to find out from observation and discussion, how well people’s needs are being met. We used all the information gathered and the rules we have, to see what outcomes there are for people in their daily lives. What the service does well: The staff work hard to try and provide activities that will interest people and provide stimulation and recreation. They also support people to maintain their personal hygiene and appearance. Staff are aware of the importance of protecting people’s privacy when they are helping them with personal care tasks. Relatives’ perceive staff as caring and able to support people effectively. We had comments like staff “have patience and understanding”, “they are always welcoming”, and “know exactly what to say and do in the right circumstances.” The environment is generally well maintained and there is considerable investment in this What has improved since the last inspection? The management team has been strengthened so that the management team have been able to improve compliance with standards and regulations. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 6 This has included improvement to individual care plans for some people. (See also below.) This means there is clearer guidance for staff in new care plans, about how they should support people properly. They also show that people are assessed to see what their nutrition is like and any risks in this area. Training for staff in infection control has improved so that they should have a better understanding of how to minimise risks to people living in the home as well as themselves. There are other areas of health and safety that have improved, for example, training staff more promptly in moving and handling people, arrangements for testing hot water, and arrangements for disposing of clinical waste. The home has been extended and provides en-suite rooms and better facilities in the new wing. This means people also have access to more communal areas and a greater variety of adapted bathing facilities. The way people are recruited has improved so that it is more robust in protecting vulnerable people, and it shows better how the process is carried out fairly for potential recruits. There has been a gradual improvement in the way that medicines are managed, the safety of systems and of recording. (See also below.) What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. People or their representatives can have the information they need to see whether the home would be able to meet their assessed needs should they decide to move in. EVIDENCE: Everybody has a copy of the booklet that is the service users’ guide in their rooms for them to refer to. The owner says an unbound copy is sent to people thinking about moving to the home, or to their representatives. Seven people answered our question about whether they have enough information about the home before deciding to move to the Laurels. Six say they did. (One person had been admitted in an emergency so they – or their relative - did not get a chance to consider any information about the service.) The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 10 We could see from records that people’s needs are assessed before they move in. If the admission is an emergency, dates show efforts are made to gather information quickly. In order to improve the process the home has recently purchased “Pabulum” blue books. These help to gather background information about people’s lives so that staff have a fuller picture about each person’s life history. Staff should then be able to communicate better with people about things that are relevant and important to each individual and to tailor activities on offer. The manager recognises that they could do better in looking at people’s religious or special cultural requirements so they can meet diverse needs more effectively. They plan to improve this within the next 12 months. The home does not admit any one solely for rehabilitation. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. New individual support plans show much better how people’s personal, physical and emotional health care needs are to be properly met. As yet, not everyone has been able to benefit from improvements in this area. Staff are aware of the importance of protecting people’s privacy but dignity has been overlooked. The way medicines are managed is continuing to improve although there remain some shortfalls. EVIDENCE: The deputy manager has only been in post since April and the manager since January. During this time they have developed new individual plans of care for people who have moved in, and started work on some care plans for The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 12 people who were already living in the home when the management team was appointed. We could see in one “new” care plan that the person’s views about their care were quoted in their own words – in relation to their personal appearance and personal care needs. This shows that the person was consulted about developing their care plan. There is a range of bathing facilities and adaptations so that people can access what is most suitable for their needs or preferences. When we last visited, individual plans were unclear about people’s mental health and how they were to be supported to maintain this, what signs there might be that someone was developing problems, and actions they should take to counteract developing problems. In the new format this is addressed. For example we saw for one person that the signs of deteriorating mental health were set out, but guidance for staff about this was not cross-referenced with the medication that may be needed occasionally as a last resort. Some people’s care plans have not been updated and are still using documentation we saw when we last visited. Some of this is out of date including information like people’s risk from falls and clarity about risks of developing pressure sores. For example, the high risk of pressure sores for the person was identified in February 2008. However, there is nothing in the person’s care plan for “safe environment,” “personal hygiene” or “skin care” showing how staff are to promote skin integrity. A health professional has told us they consider that there is quite a lot of falls in the home. We did see on one care plan that a high risk of falls had been identified but there is no indication how this is to be addressed and no evidence of liaison with other professionals about falls prevention. The deputy manager says that the equipment identified as necessary for the person is in place and training records show staff have now had training in tissue viability from the district nurse. This means they should understand what they need to be doing and why, to support people properly. A health professional has said that pressure relieving equipment is supplied to named individuals when it is needed, but there have been some concerns that it may be given to others to use from time to time, presenting a risk of crossinfection. The information the manager sent says that four people admitted to the home in the last 12 months have developed pressure sores since admission. We have not been told about all of these but district nursing staff consider there are no major problems in this area. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 13 Since our last visit there has been more effort to assess people’s nutritional needs, using a recognised screening tool. However, people’s weights are not always monitored regularly. For example, one person had no checks on their weight recorded in their notes since April. This means that there may be a delay in taking action necessary to help promote good nutrition. We looked at records for someone with diabetes. The deputy manager says that the person’s condition is stable and we could see that the district nurse had recently taken blood for testing. The care plan sets out that the person is to be supported to maintain stable blood sugars by an appropriate diet, but was unclear about how often blood sugars should be monitored. Routine testing took place monthly until October last year. There were no entries until June this year when levels were tested twice. However, the management team have made considerable progress and we have received an undertaking from one of the owners and the deputy manager that all the information will be up to date and available to staff by October. Five out of eight people we asked say they “always” have the medical care they need. One says this happens “usually” and one says “sometimes.” All three relatives who wrote to us, say that the home delivers the care and support to the person they visit, that they expect or have agreed. They all feel that the staff have the right skills and experience to look after people properly. Three staff told us they have training that helps them meet people’s needs and gives them enough knowledge about health care and medication. We looked at the way medicines are managed. We had serious concerns about these in December 2008 and our specialist pharmacist inspector has followed up these concerns at random inspections in February and May 2009. During this time progress has been made to meet outstanding requirements. The room in which medicines are stored was locked and medicines were secure. Unauthorised staff no longer have access to the room and a key handover system and record is in place. Records show temperature sensitive medicines being stored within acceptable limits. These things help ensure only trained staff have access to medicines and that they are stored in a way that keeps them safe and effective to use. The deputy manager confirmed that creams and lotions for external application are not being held securely within people’s rooms. This places their health and welfare (or that of other more confused people who may wander into their rooms) at risk of accidental harm. An assessment tool is now in use to help staff find out if people who cannot express themselves verbally are in pain. We saw this was being used so that people could be offered pain relief promptly when they needed it. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 14 There are medication profiles in the folder with medication charts. This should help staff understand what medication is being given and why. However these profiles are not always consistent with the medication charts. Some medicines were recorded on the profiles but not included on the medication charts with the potential for confusion. There is clear written information about blood testing for people prescribed anticoagulant and records show tests are going ahead as scheduled. This helps ensure that people are given the correct dosage to keep them well. Senior carers told us that the morning medicine round had been completed and everyone had received their medicines as scheduled. However, when we looked at current medication charts we found two people who had not received all or some of their medicines during the morning round and records had not been accurately completed. We found other evidence of medicines being recorded as administered when they had not been and they remained in the packs. When we compared medication chart records against medicines available to administer to people we found a number of discrepancies where we could not account for medicines. For example, for a person recently admitted to the home a week before the inspection there were already discrepancies with three of their medicines. (The number of doses recorded as given did not tally with medication amounts received and remaining.) These things show safe procedures had not always been followed to ensure people receive the medicines their doctor considers necessary to help promote their health. During previous inspections we found some medicines were out of stock and so people could not be given them. This placed the health and wellbeing of people at risk. During this inspection we found there is improvement. (Staff were giving some people who had run out of paracetamol tablets the home’s own stock. We found two further medicines that had not been available, one being a cardiovascular medicine unavailable from 16th to 17th June 2009, and the other a laxative unavailable for one day only.) Controlled drugs records show the home had not yet recorded the delivery of 56 temazepam tablets that were held in the cabinet. These were kept securely but records were not accurate. We observed part of the lunch-time medicine round. The senior carer followed safe procedures and gave people their medicines sympathetically. However, we also found three separate incident records of when tablets had been found on the floor indicating that their final ingestion had not been observed and checked by staff. We discussed this with the deputy manager The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 15 and suggested reviews with the doctor may be needed to find better alternatives. Many people had received reviews of their medicines with the person prescribing them. Notes show action has been taken when people were regularly refusing their medicines. Staff say no-one is currently being given their medicines crushed and in foodstuffs. One person manages their own inhaler and there is a risk assessment in place. However, this has not been reviewed since April 2009. In addition, the risk assessment makes no reference to monitoring the person’s ability to handle the inhaler properly, and so to make sure they were get the medication properly and safely when they need it. Since previous inspections, the home has a reduced number of people prescribed medicines of a psychotropic (and potentially sedative) nature for occasional use. (For example, these may be prescribed to control agitation or anxiety.) Where such medicines are prescribed their use is less than we have seen previously. Records show staff are now using such medicines when their use is justified by the person’s condition. For one person, there is brief written guidance for the use of such a medicine. However, care plan guidance relating to the management of the person’s agitation or anxiety does not indicate specifically when the medicine should be considered for use after non-medicinal interventions have been unsuccessful. For another person, it was unclear if such a medicine was still prescribed. There were instructions available for its use and it was included in the medication profile but it was not present on the current medication chart. The deputy manager reported that the home now has a continuous programme of monitoring and assessing the competence of members of staff who have received training and are authorised to handle and administer medicines. She confirmed that of nine members of care staff only two had yet to be monitored and assessed. Training records confirm this information showing that the home is trying hard to make sure that staff are competent to follow safe procedures for administering medicines. We know from safeguarding information that people’s dignity is not always upheld. However, we could see from records and staff files that this is being addressed by further training and discussion where staff have acted inappropriately. One person told us “the staff treat me OK and respect me.” We did hear staff knocking on doors before entering people’s rooms. We also heard one staff member reminding someone they had a letter they may wish to open. These things help show that people’s privacy is respected. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. People have opportunities to engage in meaningful activity and their families are welcomed when they visit. EVIDENCE: We did not look in detail at the provision of social activities, but feedback from people living in the home, observations and records do not indicate that the standard has declined. When we last visited we used 2 hours of specific and detailed observations for five people revealing good outcomes, activities and interactions in the home which we did not repeat on this visit. There are notices showing activities that are to take place and photographs of some of the things people have been able to do. The home employs an activities coordinator to help promote activities for people. Six out of 7 people who wrote to us say there are “always” activities they can take part in. One person says these take place “sometimes”. Two people told us that they had plenty to do. One says “I don’t go” to the organised activities The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 17 and prefer to spend time in their own room reading papers, doing puzzles and watching sport on the television. One of the people we case tracked had a new care plan which reflected that the person liked to go out to the shops to get a paper or lottery ticket and that staff were to support this where possible. One relative we spoke to says that staff are “always welcoming” and help the person they visit get in the car safely for a trip out. They say in this way staff help them to “spend quality time” with their spouse. The three relatives who wrote to us say that the home always helps people to stay in touch with them. One adds that the staff do well in “knowing exactly what to say and do at the right moment.” People are able to keep and handle their own money if they are able to manage this. We know that one person did this because they had become confused about some money that they had spent. The deputy manager says she followed this up with the person concerned and their relative, after our visit. One person told us “I’m quite happy with things.” We asked people about their meals. Menus are displayed and at our last visit we heard people being consulted about choices. One person told us “I am not a fish and chips person and couldn’t eat it.” They told us there was no choice but the person sitting with them told us “yes, there is.” Another told us that they had chosen what they were going to have for their tea. The menu said the choice was pork pie and salad but the person had declined this and said they had asked to have a ham sandwich and said that was all they would want after their lunch. Another person did comment that they would like to see more variety of food at tea time. This may mean they are unaware of all the options that are open to them and they are not listed on the menu displayed. One says “the food is OK” and another that the “meals are good”. All of the people who completed our survey say meals are usually or always good. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. People have access to a complaints procedure that is now more robustly implemented. There are measures in place to help protect people from abuse. EVIDENCE: Complaints are recorded. The results of investigations are clearly recorded together with feedback that is given to the complainant. Three out of the 7 people say that they know how to make a complaint if they need to. Four do not but all of them say there is someone they can speak to informally if they are not happy. The complaints procedure is posted on the back of each person’s door as a reminder, so that they or their representatives could see how to go about making a complaint and who to talk to. In practice, many of the people living in the home would need the support of others to make their concerns known. Others are able to speak up for themselves and records show that issues are followed up. We spoke to one of the people who had made complaints. They say they are “happy with what has been done” and “it’s all sorted out now.” They named the manager and the deputy manager as people they feel they can go to if they have any concerns. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 19 All three relatives who wrote to us say that they know how to make a complaint if they need to and that the service has “always” responded appropriately if they have needed to raise any concerns. The home has learnt from safeguarding procedures in the past, what they need to refer promptly to others to ensure people are not being placed at risk of abuse. We had concerns that things were not referred properly in the past but know that the new manager has been in contact with the adult protection team when this has been needed. Staff do have access to training to enable them to recognise and respond to abuse appropriately and the protection of vulnerable people is also covered in induction. Where the conduct of staff has led to concerns the home has also implemented disciplinary measures and provided extra training, going back to basics, so that staff understand clearly what is expected practice. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. People live in a comfortable, safe and clean environment. EVIDENCE: Work continues to make sure that the home is maintained in good condition. Rooms in the original part of the building do not have en-suite facilities, but those in the new extension do. There is a secure courtyard garden at the centre of the home that people can access safely by a ramp with a hand rail. One person told us “I like being outside whatever the weather” and added that “I’ve always done it.” There is a canopy to one side that will provide some shade or shelter when this is needed. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 21 Fire detection systems are tested regularly to make sure they will work in an emergency and give warning so that people are able to get out safely. People are able to bring in some of their own belongings to make their rooms more personal. One person has their own room key and we heard another discussing with staff that this might be needed for them, to prevent others wandering into their room. The owners and management team are, based on discussion, looking at ways to make bathrooms more homely so that people feel more comfortable using them. (There is a choice of different types of baths so that individual needs and abilities can be catered for.) Areas of the home that we saw, were clean. Four people say it is “always” clean and fresh, and four say “usually”. No one expressed concerns about cleanliness. Domestic hours have been increased and staff have been provided with additional guidance about hand hygiene. The manager says they have also carried out a self assessment for delivering safe and clean care and produced an action plan to ensure this is promoted well. We discussed hand washing facilities and how infection control might be improved by the use of appropriate gels after hand washing. The owner is considering fitting dispensers in areas that people living in the home would not access (to avoid accidental ingestion), and where staff or visitors could use them to contribute to better infection control. We saw from the training record and the information the manager sent to us that over half the staff now have training in infection control so that they understand better how to minimise the risk to those living in the home and to themselves. The training record shows that the deputy manager has had additional training in this area to help ensure staff follow good procedures. This is an improvement since our last visit. Since our last visit, a contract has been arranged for the proper disposal of clinical waste. This also helps minimise risks of infection to others. There are plans to upgrade laundry facilities so we will look at these next time. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures have improved and the management team recognise where the competence of the staff team could be improved to support people effectively. EVIDENCE: We made three requirements under this section last time. They have been met. Last time we visited, staff told us that sometimes they were short staffed and that weekends were particularly unbalanced with more staff rostered on some than others. This time all the staff who completed our surveys say they feel there are “always” enough of them to meet people’s needs. When we visited there were 7 staff on shift reflecting that numbers of people living in the home have increased. (There are still vacancies.) Although staff were very busy, we did not find on checking the call bell panel, that people were waiting very long for their requests for help to be responded to. The perception of a health professional we spoke to is that there are more staff around when they visit the home. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 23 The rota and information from the manager shows there are additional staff on duty from 7am to 8am (overlapping with night staff), and at tea time. There is an extra staff member on night duty because of the extension to the building and the increase in numbers. This helps to respond to people’s needs at busier times of day. However, only two out of 8 people who answered the question in our survey say staff are always available when they need them, 5 say this is “usually” the case. One says “sometimes.” We asked about this and whether people had to wait long for help when they used their call bell. One told us they “sometimes have to wait” and “have to wait your turn” but that they were “OK with that.” Another person told us that “sometimes they don’t put enough on, and they can be short and not enough of them when you need them.” The manager has committed the service in writing, to continuing to review staffing levels as numbers and needs of people change to make sure they can support people properly. We have not therefore repeated the requirement we made last time. Relatives responded to us positively about the quality of staff on duty. One told us “they have patience, understanding and sympathy” and know “exactly what to say and do at the right moment.” All three wrote that the staff “always” have the right skills and experience to look after people properly. Information from the manager shows that under a third of care staff have National Vocational Qualifications to give them the underpinning knowledge they should have, to help them understand and respond to people’s needs effectively. The manager recognises in information sent to us that they could do better in ensuring that all staff have access to training. Staff are offered in-house “awareness” training covering a variety of areas, to make sure they understand their roles effectively and can support people as the management team expects. There has been an improvement in training people in moving and handling, and records show this is delivered more promptly when new staff start work. This helps make sure that staff are able to support people safely in this area. The training information shows that more of the training is delivered by others rather than “in house” as previously. The manager plans to improve this further by exploring options for distance learning to help staff improve their skills. We saw some information about training from external providers – for example use of medication in dementia, person centred care, and basic dementia awareness. Some of this is free. However, some dates have passed without staff being able to benefit from attending them and so to improve their skills and understanding. The deputy manager has attended training “for managing dementia” and says staff “cope with dementia quite well.” However, they have The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 24 missed training opportunities (based on dates and information available in the home) that would help improve their knowledge and skills in this area. There is an improvement in the way progress during induction is recorded, showing what new staff have covered and the progress they are making. Recruitment records now show that employment histories are explored, and that all references and checks are completed before people start work at the home. This helps show that a more robust process is in place for ensuring that staff taken on are suitable to work with vulnerable people. Staff files are more organised and show that interviews are more structured and the results recorded. This helps promote fairness in the recruitment process. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The existing management team have made progress towards running the home more effectively, taking into account the views, and welfare of people living in the home They have identified things for themselves that they feel need to improve. EVIDENCE: Since our last visit to the home, the management arrangements have changed. A new manager was appointed in January and applied for registration as well as starting to work towards the qualifications that will help under understand and fulfil her role more effectively. A deputy manager The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 26 joined the team in April and there is also a care quality monitoring manager to help strengthen the team. We can see from work towards requirements we made that the management team have been making improvements in the way the service is run and how well it complies with regulations. However, the manager will be leaving at the end of September. One of the owners tells us there are plans to recruit in the near future and an appropriate and competent person will need to be in place promptly to ensure progress is maintained. The information in the annual quality assurance assessment sent to us contained a better range of evidence than when it was last submitted and we were able to check a sample of this. The information also shows where the management team feel they can make further improvements and how they are going to do this. The responsible individual has also started visiting the home on a monthly basis to look at and report on service quality to the manager and the company, so that plans for improvement can be developed. This allows opportunities for consultation with people living, visiting and working in the home. There are also efforts to look at aspects of the quality of the service and to develop improvements arising from findings – for example in relation to falls and accidents. Last time we visited there were no copies of records of incidents happening in the home and which the manager is obliged to tell us about. This time, copies of the information was available (with the exception of notifications about pressure ulcers which people have developed. We need to be told about these if they are grade 2 or above.). These notifications provide additional information about the service that the management team can use to check if there are problems, issues or hazards that may need addressing. Last time we visited we found that staff were not being appropriately supervised so their performance could be properly monitored and their development and training needs be identified and addressed. We could see this time that there has been some improvement in this area and that staff who are responsible for supervising others have been given some training. One person, in post from the middle of February had two supervisions recorded showing the frequency does not yet meet what is expected, but systems for monitoring this have been improved. Three out of four staff who completed our surveys say the manager “regularly” gives them enough support and meets with them to discuss their work. One says this happens “usually”. The management team have also undertaken in writing to us that they plan to improve this area further and have developed a policy for appraisal and performance review that they now need to ensure is implemented. For this reason we have not repeated the requirement. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 27 Staff now have training in moving and handling people safely, more quickly when they are appointed. The strengthened management team should now be able to monitor that staff put their training into practice so promoting people’s safety. We had some concerns that the risk assessment for fire safety in the home and how risks were to be minimised, was not available and so could not be monitored to make sure it was being adhered to. Additionally, two staff on duty were not able to tell us exactly how many people there were living at the home. This would present concerns in the event of fire as they would not be able to advise fire officers whether all service users had been safely evacuated. There have been improvements in the frequency with which hot water temperatures can be tested so that people are not at risk of scalding, and since our last visit thermometers have been purchased to enable staff to do this. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 2 x 2 The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Timescale for action All outstanding care plan updates 01/10/09 must be completed, setting out how people’s needs are to be met, and they must be kept up to date. If this does not happen, people are at risk of not having their needs met. 2. OP7 15 The process of completing new care plans and reviewing them must show how people (or their representatives) are involved. This is so people are consulted about how they wish their needs to be met. 3. OP8 15 Where people have health conditions such as diabetes, care plans must be clear about who monitors the condition, how, and when. This is so any changes or deterioration would be identified more easily and could be addressed. The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 30 Requirement 01/10/09 01/10/09 4. OP8 13(4) Action must be taken to address concerns about people who are at high risk of falls. (This may include liaising with other health professionals who can help develop a strategy to reduce falls.) Medicines held in people’s rooms must be stored securely at all times. This is to safeguard people’s health and welfare. Medicines must be given to people as prescribed - by members of staff who follow safe procedures at all times. (This must be demonstrated by full and accurate record-keeping practices.) The management team must set out how risks of outbreak or spread of fire are to be minimised. This is to promote the safety of people living in the home. The management team must take steps to ensure staff on duty always know how many people there are living in the home. This is so they can respond promptly to unexplained absences and are aware of how many people need to be evacuated if there fire brigade ever needs to know 01/10/09 5. OP9 13(2) 11/09/09 6. OP9 13(2) 11/09/09 7. OP38 23(4a) 11/09/09 8. OP38 13(4) 11/09/09 The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8 Good Practice Recommendations Care plans should be specific about the aids that are to be used to help promote skin integrity for people who are at risk of developing pressure sores. Where people’s mental health or anxiety means they need medicines for occasional use to help them feel better, care plans should cross – reference consistently with guidance about the use of the medicine. Where people administer their own medicines, reviews of risk assessments should take place regularly, and where people handle their own inhalers their ability to use the inhaler properly should also be monitored. This is to make sure people receive the medication that has been prescribed to them, and continue to manage this safely. 4. OP9 Written medication profiles should be checked regularly for accuracy and promptly updated when changes are made to people’s medication. This is to help avoid confusion and make sure staff are clear what medication is actually in use and why. 5. OP9 People who have difficulty swallowing their medicines properly should have medication reviews by their prescribers. This is to make it easier for people to take the medicines that are needed to keep them well. 2. OP8 3. OP9 The Laurels DS0000064440.V376976.R01.S.doc Version 5.2 Page 32 Care Quality Commission Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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